Healthcare Provider Details

I. General information

NPI: 1306915418
Provider Name (Legal Business Name): SUSAN NILSEN WALSH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 AIRPORT ROAD
HOOPA CA
95546
US

IV. Provider business mailing address

PO BOX 1221 2000 FRIDAY RIDGE ROAD
WILLOW CREEK CA
95573
US

V. Phone/Fax

Practice location:
  • Phone: 530-625-4261
  • Fax: 530-625-5171
Mailing address:
  • Phone: 530-629-3515
  • Fax: 530-625-5171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP11681
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: